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    Erectile dysfunction or "ED" is defined as the inability to obtain or maintain an erection sufficient for satisfactory sexual activity. It is the most widely studied disorder of male sexual function. Other less publicized disorders include: disorders of sexual desire, ejaculatory and orgasm disturbances, as well as disorders involving penile pain or curvature. ED is highly prevalent in the adult male population, and may effect as many as 50% of men between the ages of 40-70 years old.

    In order to develop an erection, blood must be able to rapidly enter the male penis through two small arteries that course through the lower pelvis, just under the scrotum. The trigger for this blood flow event lies within the muscles that line the inside of the penis which relax involuntarily when there is sexual stimulation. Over the last 15 years a large amount of research has gone into defining the physiology of male erections. What has become clear is that for a man to develop a satisfactory erection there must be adequate blood flow, a well functioning nervous system, and a reasonable level of circulating male hormones such as testosterone. Diseases that affect any of these body systems can cause ED. In fact, population studies have confirmed that age, high blood pressure, diabetes, heart disease, cigarette smoking, excessive alcohol consumption, and low male hormone levels are significant risk factors for the development of ED. In addition, there are a large number of medications that are used to treat these disorders which may also cause ED.

    Prior to the late 1990s, the only treatment available to men with ED were medications that could be injected directly into the penis, a vacuum canister that was applied to the outside of the penis and created an erection through suction, and surgical placement of a prosthetic device into the penis and scrotum. While these treatment options are still available, and provide very satisfactory results in many men with ED, they are not the first choice for the majority of men with ED. What was clearly needed was a pill that could be taken to improve erections.

    Assessing the patient with sexual dysfunction: History of sexual dysfunction

    Seek to understand the patient´s sexual expectations, needs and behaviour and identify sexual problems, and also any misconceptions. Psychological factors are always important, either as an emotional reaction to sexual dysfunction or as a consequence of a socially or physically disabling disease. Try to interview the patient’s partner separately. As always in neurology chronology is very important. Was the onset sudden, rapid or gradual, the course progressive or episodic? Ask about sexual desire. The term Hypoactive Sexual Desire Disorder (HSDD) is sometimes used to define a persistent or recurrent reduction in sexual fantasies, thoughts, desire for sexual activity, alone or with a partner, with inability to respond to sexual cues that would be expected to trigger responsive sexual desire. To be significant, these symptoms be associated with personal distress (Basson et al 2004).

    Sensory aspects of sexual function should be elucidated. Present or past disturbances of sensitivity in the region corresponding to the sacral segments are particularly important, as well as pain during sexual arousal or intercourse, and pelvic or superficial dyspareunia. If a man, does the patient have nocturnal erections, morning erections, erections evoked by visual, auditory or psychogenic stimuli and erections evoked or enhanced by genital stimulation? What is the quality of penile tumescence? Is erection sufficient for penetration? Is erection maintained during sexual intercourse? Has priapism or painful nocturnal erection occurred? Women should be asked about erections of the clitoris and vaginal lubrication. Are these female reactions evoked by visual, emotional or direct genital stimulation?

    In males, ejaculation should be described. Does the patient have premature or retarded ejaculation, or even absence of ejaculation? Is the ejaculation dribbling, i.e. are there emissions of semen through the urethra without contractions of pelvic floor muscles? Retrograde ejaculation into the bladder with spermatozoa in urine implies an internal urinary sphincteric disorder. Aspermia is lack of emission of semen. Both can be described as dry ejaculation. In women, is there urinary incontinence during sexual intercourse or does forceful ejaculation of fluids from the urethra occur during orgasm (so-called female ejaculation)?

    Orgasm can be defined as the sum of all physiological events that occur during the sexual climax and how the individual experiences this, including sexual pleasure. What is the capacity to achieve an orgasm? Does the person – male or female – actually feel the pelvic floor muscle contractions? How is the quality of orgasmic sensations and experiences? An orgasm may be anhedonic, i. e. without pleasurable sensations. Spontaneous orgasms do also occur and orgasms may be painful.

    Formal questionnaires can be used to obtain standardised information, e.g., the Brief Male Sexual Function Inventory for Urology (O`Leary et al 1995) and the International Index of Erectile Function (IEEF, 1997), but these are not recommended for assessment of individual patients (Lue 1996).

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